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Morphology of the major papilla predicts ERCP procedural outcomes and adverse events

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Abstract

Background

The morphology of the major papilla affects the difficulty of endoscopic retrograde cholangiopancreatography (ERCP), but no associations with adverse events have previously been established. We aimed to assess whether papillary morphology predicts ERCP adverse events.

Methods

A retrospective analysis was performed of a prospective registry of patients undergoing ERCP for biliary indications. The primary outcome was post-ERCP pancreatitis (PEP), with secondary outcomes including other adverse events and procedural outcomes such as inadvertent pancreatic duct cannulation, cannulation time, and attempts. Papillae were classified as normal (Type I), small or flat (Type II), bulging (Type IIIa), pendulous (Type IIIb), creased (Type IV), or peri-diverticular (Type D). Outcomes were ascertained prospectively at 30 days from index procedures.

Results

A total of 637 patients with native papillae were included. Compared to Type I papillae, Type II and Type IIIb papillae were associated with PEP, with adjusted odds ratios (AOR) of 7.28 (95% confidence intervals, CI, 1.84–28.74) and 4.25 (95% CI 1.26–14.32), respectively. Type II and IIIb papillae were associated with significantly longer cannulation times by 5.37 (95% CI 2.39–8.35) and 4.01 (95% CI 1.72–6.30) minutes, respectively. Type IIIb papillae were associated with lower deep cannulation success (AOR 0.17, 95% CI 0.06–0.48).

Conclusion

Papillary morphology is an important factor influencing both ERCP success and outcomes. Understanding this is key for managing intraprocedural approaches and minimizing adverse events.

Prospective registry registration

Clinicaltrials.gov identifier NCT04259580.

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Fig. 1

adapted from Haraldsson et al. [10]. Type I: normal—no distinctive features. Type II: flat/small—diameter less than 3 mm, or approximately 9 Fr. Type IIIa: protruding/bulging—large intraduodenal portion with extrusion into the lumen. Type IIIb: pendulous/redundant—several hooding folds or with caudal orientation of biliary orifice. Type IV: creased/ridged—ductal mucosa extending distally along a crease/ridge. Type D: involved with a periampullary diverticulum

Fig. 2

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Abbreviations

ASGE:

American Society for Gastrointestinal Endoscopy

CI:

Confidence intervals

CReATE:

Calgary registry for advanced and therapeutic endoscopy

DOAC:

Direct oral anticoagulant

ERCP:

Endoscopic retrograde cholangiopancreatography

NKP:

Needle-knife papillotomy

NSAID:

Non-steroidal anti-inflammatory drug

PD:

Pancreatic duct

PEP:

Post-ERCP pancreatitis

References

  1. Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM (2017) Adverse events associated with ERCP. Gastrointest Endosc 85:32–47

    Article  Google Scholar 

  2. Gottlieb K, Sherman S (1998) ERCP and biliary endoscopic sphincterotomy-induced pancreatitis. Gastrointest Endosc Clin N Amer 8:87–114

    CAS  Google Scholar 

  3. Tse F, Yuan Y, Bukhari M, Leontiadis GI, Moayyedi P, Barkun A (2016) Pancreatic duct guidewire placement for biliary cannulation for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane DB Syst Rev. https://doi.org/10.1002/14651858.CD010571.pub2

    Article  Google Scholar 

  4. Masci E, Mariani A, Curioni S, Testoni PA (2003) Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy 35:830–834

    Article  CAS  Google Scholar 

  5. Elmunzer BJ, Scheiman JM, Lehman GA, Chak A, Mosler P, Higgins PD, Hayward RA, Romagnuolo J, Elta GH, Sherman S, Waljee AK, Repaka A, Atkinson MR, Cote GA, Kwon RS, McHenry L, Piraka CR, Wamsteker EJ, Watkins JL, Korsnes SJ, Schmidt SE, Turner SM, Nicholson S, Fogel EL (2012) A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 366:1414–1422

    Article  CAS  Google Scholar 

  6. Matsushita M, Uchida K, Nishio A, Takakuwa H, Okazaki K (2008) Small papilla: another risk factor for post-sphincterotomy perforation. Endoscopy 40:875–876

    Article  CAS  Google Scholar 

  7. Horiuchi A, Nakayama Y, Kajiyama M, Tanaka N (2007) Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla. Clin Gastroenterol Hepatol 5:1113–1118

    Article  Google Scholar 

  8. Hew S, Bechara R, Hookey L (2020) Papillary morphology influences biliary cannulation: beware the small papilla! Gastrointest Endosc 91:959

    Article  Google Scholar 

  9. Watanabe M, Okuwaki K, Kida M, Imaizumi H, Yamauchi H, Kaneko T, Iwai T, Hasegawa R, Miyata E, Masutani H, Tadehara M, Adachi K, Koizumi W (2019) Transpapillary biliary cannulation is difficult in cases with large oral protrusion of the duodenal papilla. Dig Dis Sci 64:2291–2299

    Article  Google Scholar 

  10. Haraldsson E, Lundell L, Swahn F, Enochsson L, Lohr JM, Arnelo U (2017) Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study. United Eur Gastroent 5:504–510

    Article  CAS  Google Scholar 

  11. Haraldsson E, Kylanpaa L, Gronroos J, Saarela A, Toth E, Qvigstad G, Hult M, Lindstrom O, Laine S, Karjula H, Hauge T, Sadik R, Arnelo U (2019) Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian association for digestive endoscopy study group for ERCP. Gastrointest Endosc 90:957–963

    Article  Google Scholar 

  12. Adler DG (2019) ERCP biliary cannulation difficulty as a function of papillary subtypes: a tale of shapes and Shar-Pei dogs. Gastrointest Endosc 90:964–965

    Article  Google Scholar 

  13. Forbes N, Koury HF, Bass S, Cole M, Mohamed R, Turbide C, Gonzalez-Moreno E, Kayal A, Chau M, Lethebe BC, Hilsden RJ, Heitman SJ (2020) Characteristics and outcomes of ERCP at a Canadian tertiary centre: initial results from a prospective high-fidelity biliary endoscopy registry. J Can Assoc Gastroenterol. https://doi.org/10.1093/jcag/gwaa007

    Article  PubMed  PubMed Central  Google Scholar 

  14. Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42:377–381

    Article  Google Scholar 

  15. Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, Jacobson BC, Mergener K, Nemcek A Jr, Petersen BT, Petrini JL, Pike IM, Rabeneck L, Romagnuolo J, Vargo JJ (2010) A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 71:446–454

    Article  Google Scholar 

  16. Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, Liguory C, Nickl N (1991) Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 37:383–393

    Article  CAS  Google Scholar 

  17. Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, Deviere J, Dinis-Ribeiro M, Dumonceau JM, Giovannini M, Gyokeres T, Hafner M, Halttunen J, Hassan C, Lopes L, Papanikolaou IS, Tham TC, Tringali A, van Hooft J, Williams EJ (2016) Papillary cannulation and sphincterotomy techniques at ERCP: European society of gastrointestinal endoscopy (ESGE) clinical guideline. Endoscopy 48:657–683

    Article  Google Scholar 

  18. Dumonceau JM, Andriulli A, Elmunzer BJ, Mariani A, Meister T, Deviere J, Marek T, Baron TH, Hassan C, Testoni PA, Kapral C (2014) Prophylaxis of post-ERCP pancreatitis: European society of gastrointestinal endoscopy (ESGE) Guideline—updated June 2014. Endoscopy 46:799–815

    Article  Google Scholar 

  19. Wani S, Han S, Simon V, Hall M, Early D, Aagaard E, Abidi WM, Banerjee S, Baron TH, Bartel M, Bowman E, Brauer BC, Buscaglia JM, Carlin L, Chak A, Chatrath H, Choudhary A, Confer B, Cote GA, Das KK, DiMaio CJ, Dries AM, Edmundowicz SA, El Chafic AH, El Hajj I, Ellert S, Ferreira J, Gamboa A, Gan IS, Gangarosa L, Gannavarapu B, Gordon SR, Guda NM, Hammad HT, Harris C, Jalaj S, Jowell P, Kenshil S, Klapman J, Kochman ML, Komanduri S, Lang G, Lee LS, Loren DE, Lukens FJ, Mullady D, Muthusamy RV, Nett AS, Olyaee MS, Pakseresht K, Perera P, Pfau P, Piraka C, Poneros JM, Rastogi A, Razzak A, Riff B, Saligram S, Scheiman JM, Schuster I, Shah RJ, Sharma R, Spaete JP, Singh A, Sohail M, Sreenarasimhaiah J, Stevens T, Tabibian JH, Tzimas D, Uppal DS, Urayama S, Vitterbo D, Wang AY, Wassef W, Yachimski P, Zepeda-Gomez S, Zuchelli T, Keswani RN (2019) Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees. Gastrointest Endosc 89:1160-1168.e1169

    Article  Google Scholar 

  20. Asfeldt AM, Straume B, Paulssen EJ (2007) Impact of observer variability on the usefulness of endoscopic images for the documentation of upper gastrointestinal endoscopy. Scand J Gastroenterol 42:1106–1112

    Article  Google Scholar 

  21. Smith ZL, Elmunzer BJ, Cooper GS, Chak A (2020) Real-world practice patterns in the era of rectal indomethacin for prophylaxis against post-ERCP pancreatitis in a high-risk cohort. Am J Gastroenterol 115:934–940

    Article  Google Scholar 

  22. Avila P, Holmes I, Kouanda A, Arain M, Dai SC (2020) Practice patterns of post-ERCP pancreatitis prophylaxis techniques in the United States: a survey of advanced endoscopists. Gastrointest Endosc 91:568-573.e562

    Article  Google Scholar 

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Funding

NB Hershfield Chair in Therapeutic Endoscopy, University of Calgary.

Author information

Authors and Affiliations

  1. Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada

    Rachid Mohamed, Emmanuel Gonzalez-Moreno, Ahmed Kayal, Sydney Bass, Martin Cole, Christian Turbide, Millie Chau, Robert J. Hilsden, Steven J. Heitman & Nauzer Forbes

  2. Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    B. Cord Lethebe & Hannah F. Koury

  3. Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada

    Emmanuel Gonzalez-Moreno, Ahmed Kayal, Darren R. Brenner, Robert J. Hilsden, Steven J. Heitman & Nauzer Forbes

  4. Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, AB, Canada

    Darren R. Brenner

  5. Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Darren R. Brenner

  6. Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA

    B. Joseph Elmunzer

  7. Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Rajesh N. Keswani

  8. Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

    Sachin Wani

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  1. Rachid Mohamed
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  2. B. Cord Lethebe
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  16. Nauzer Forbes
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Contributions

NF and RM conception and design; All authors analysis and interpretation of the data; RM and NF drafting of the article; All authors critical revision of the article for important intellectual content; All authors final approval of the article.

Corresponding author

Correspondence to Nauzer Forbes.

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Disclosures

Dr. Mohamed is a consultant for Boston Scientific. Dr. Elmunzer is a consultant for Takeda Pharmaceuticals. Dr. Keswani is a consultant for Boston Scientific and Motus GI. Dr. Wani is a consultant for Boston Scientific and Medtronic. Dr. Forbes is a consultant for Boston Scientific, is on the speakers’ bureau for Pentax Medical, and has received unrelated funding from Pentax Medical. All disclosures are unrelated to this work. Mr. Lethebe, Dr. Gonzalez-Moreno, Dr. Kayal, Dr. Bass, Dr. Cole, Dr. Turbide, Ms. Chau, Ms. Koury, Dr. Brenner, Dr. Hilsden, and Dr. Heitman have no potential conflicts of interest or financial ties to disclose.

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Mohamed, R., Lethebe, B.C., Gonzalez-Moreno, E. et al. Morphology of the major papilla predicts ERCP procedural outcomes and adverse events. Surg Endosc 35, 6455–6465 (2021). https://doi.org/10.1007/s00464-020-08136-9

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